Endoscopic Submucosal Dissection Is Safe and Effective for Lesions Located at the Anorectal Junction: Analysis from Two Referral European Centers

Introduction

Endoscopic submucosal dissection (ESD) is a well-established resection technique for colorectal superficial tumors, but its role in the treatment of anorectal junction (ARJ) lesions still remains to be determined. With this study, we aimed to evaluate the feasibility, safety, and efficacy of ESD for the resection of ARJ lesions, in comparison to more proximal rectal lesions.

Methods

We performed a retrospective analysis of prospectively collected data concerning all consecutive rectal ESD procedures performed in two European centers, from 2015 to 2021.

Results

A total of two hundred and fifty-two rectal lesions were included. Sixty (24%) were ARJ lesions, and the remaining 192 (76%) were located proximally. Technical success was achieved in 248 procedures (98%), and its rate was similar in both locations (p = 0.246). Most of the lesions presented high-grade dysplasia/Tis adenocarcinoma (54%); 36 (15%) had submucosal adenocarcinoma, including 20 superficial (sm1) and 16 deeply invasive (>SM1) T1 cancers. We found no differences between ARJ and rectal lesions in regard to en bloc resection rate (100% vs. 96%, p = 0.204), R0 resection rate (76% vs. 75%, p = 0.531), curative resection rate (70% vs. 70%, p = 0.920), procedures' median duration (120 min vs. 90 min, p = 0.072), ESD velocity (14 vs. 12 mm2/min, p = 0.415), histopathology result (p = 0.053), and the need for surgery due to a non-curative ESD (5% vs. 3%, p = 0.739). Also, there was no statistically significant difference that concerns delayed bleeding (7% vs. 8%, p = 0.709), perforation (0% vs. 5%, p = 0.075), or the need for readmission (2% vs. 2%, p = 0.939). Nevertheless, anorectal stenosis (5% vs. 0%, p = 0.003) and anorectal pain (9% vs. 1%, p = 0.002) were significantly more frequent in ARJ lesions.

Conclusion

ESD is a safe and efficient resection technique for the treatment of rectal lesions located in the ARJ.

Trans-anal endoscopic microsurgery for non- adenomatous rectal lesions

BACKGROUND

Trans-anal endoscopic microsurgery (TEM) enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer. The rectum and retro-rectal space might be the origin of uncommon neoplasms, benign and aggressive, certain require radical trans-abdominal surgery, while others can be treated by a less aggressive approach. In this study we report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.

AIM

To report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.

METHODS

Between January 2008 to December 2019 a retrospective analysis was completed for all patients who underwent TEM for non-adenomatous rectal lesion or retro-rectal mass in our institution. Patients were discharged once diet was well tolerated and no complications were identified. They were evaluated at 3 wk post operatively, then at 3-mo intervals for the first 2 years and every 6 mo depending on the nature of the final pathology. Clinical examination and rectoscopy were performed during each of the follow-up visits.

RESULTS

Out of 198 patients who underwent TEM during the study period, 18 had non-adenomatous rectal or retro-rectal lesions. Mean age was 47 years. The mean size of the lesions was 2.9 mm, with a mean distance from the anal margin of 7.9 cm. Mean surgical time was 97.8 min. There were no intra-operative neither late post-operative complications. Mean length of stay was 2.5 d. Mean patient follow-up duration was 42 mo.

CONCLUSION

TEM allows for reduced morbidity given its minimally invasive nature. Surgeons should be familiar with the technique but careful patient selection should be considered. It can be used safely for uncommon rectal and selected retro-rectal lesions without compromising outcomes. We believe that it should be reasonably considered as one of the surgical methods when treating rare lesions.

Excision of malignant and pre-malignant rectal lesions by transanal endoscopic microsurgery in patients under 50 years of age

BACKGROUND

The most common technique for treating benign and early malignant rectal lesions is transanal endoscopic microsurgery (TEM). Local excision is an acceptable technique for high-risk and elderly patients, but there are hardly any data regarding young patients.

AIM

To describe TEM outcomes in patients under 50 years of age.

METHODS

We collected demographic, clinical, and pathological data from all patients under the age of 50 years who underwent the TEM procedure at Hasharon Rabin Medical Center from January 2005 to December 2018.

RESULTS

During the study period, a total of 26 patients under the age of 50 years underwent TEM procedures. Their mean age was 43.3 years. Eleven (42.0%) were male. The mean operative time was 67 min, and the mean tumor size was 2.39 cm, with a mean anal verge distance of 8.50 cm. No major intraoperative or postoperative complications were recorded. The median length of stay was 2 d. Seven (26.9%) lesions were adenomas with low-grade dysplasia, four (15.4%) were high-grade dysplasia adenomas, two were T1 carcinomas (7.8%), and three were T2 carcinomas (11.5%). No residual disease was found following endoscopic polypectomy in two patients (7.8%), but four (15.4%) had other pathologies. Surgical margins were negative in all cases. Local recurrence was detected in one patient 33 mo following surgery.

CONCLUSION

Among young adult patients, TEM for benign rectal lesions has excellent outcomes. It may also offer a balance between the efficacy of complete oncologic resection and postoperative quality of life in the treatment of rectal cancer. In some cases, it may be considered an alternative to radical surgery.

Systematic review of functional outcomes and quality of life after transanal endoscopic microsurgery and transanal minimally invasive surgery: a word of caution

PURPOSE

The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS).

METHODS

A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study.

RESULTS

A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis.

CONCLUSIONS

These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.

Quantitative Elastography of Rectal Lesions: The Value ofShear Wave Elastography in Identifying Benign and Malignant Rectal Lesions

We evaluate the value of shear wave elastography (SWE) in diagnosing benign and malignant rectal lesions. A total of 96 lesions were reviewed in this study; endorectal ultrasound (ERUS) and SWE examinations were performed before surgery in all cases. Elasticity parameters including mean elastographic index (E_mean), maximum elastographic index (E_max) and minimum elastographic index (E_min) were analyzed. Correlations between elastographic parameters and histopathological results were studied. Inter-observer and intra-observer agreement was analyzed. Of the 96 rectal lesions, 72 were malignant and 24 were benign. Compared with ERUS, ERUS + SWE had higher sensitivity (93.0% vs. 88.9%), specificity (83.3% vs. 79.2%), positive predictive value (94.4% vs. 92.7%), negative predictive value (80.0% vs. 70.4%) and overall accuracy (90.6% vs. 86.4%). In receiver operating characteristic curve analysis, E_mean and E_max had larger areas under the curve: 0.92 and 0.91, respectively. The optimal cutoff value was 61.3 kPa for E_mean (sensitivity = 88.9%, specificity = 87.5%) and 63.4 kPa for E_max (sensitivity = 94.4%, specificity = 83.3%). We obtained κ values of 0.83 (95% confidence interval [CI]: 0.72-0.95) for ERUS and 0.90 (95% CI: 0.81-0.99) for ERUS + SWE of differential diagnosis in two observers. The intra-class correlation coefficients for intra-observer variability of stiffness (E_mean) in malignant lesions, benign lesions, surrounding normal rectal wall in malignant lesions and surrounding normal rectal wall in benign lesions were 0.91 (95% CI: 0.86-0.94), 0.94 (95% CI: 0.88-0.97), 0.92 (95% CI: 0.88-0.95) and 0.89 (95% CI: 0.77-0.95), respectively. SWE is a promising tool that yields valuable quantitative data additional to that provided by ERUS examination in rectal lesions. The cutoff value 61.3 kPa for E_mean may serve as a complementary tool in diagnosis of rectal lesions.